Pickering syndrome in a patient with a single kidney: role of renal artery stenting.

Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations and is usually resistant to medical therapy. Of these clinical manifestations is Pickering syndrome which is characterized by bilateral renal arterial occlusion inflow lesions, flash pulmonary edema, acute kidney injury, and hypertensive emergencies in the setting of a preserved left ventricle function. Stenting techniques have been used extensively to treat symptomatic renal artery stenosis with excellent primary patency rate, however have failed to demonstrate a long-term benefit over the optimal medical management alone in randomized trials. However, accumulating evidence suggests that stenting is justified in specific patient subgroups that have severe occlusive renal artery stenoses with significant clinical sequelae, including flash pulmonary edema, acute ischemic kidney injury, and uncontrolled hypertension. In this report we discuss the case of a 32-year-old male who presented to our center with recurrent flash pulmonary edema and hypertensive emergency and was found to have RAS, which responded well to renal artery stenting. In conclusion, correcting the renal arterial inflow stenosis is beneficial and warranted in selective clinical scenarios.

Painless myocardial ischemia is associated with mortality in patients with chronic kidney disease.

BACKGROUND: Painless myocardial ischemia (PMI) is associated with poor outcomes in the general population. We hypothesized that the presence of PMI is inversely related to the level of kidney function and is associated with impaired survival in chronic kidney disease (CKD). METHODS: A total of 356 patients who underwent percutaneous coronary intervention were assessed for PMI, which was defined as the absence of chest pain in response to balloon dilation of the affected vessel. Cox proportional hazards analysis was used to calculate 10-year all-cause mortality. RESULTS: There was an increase in PMI occurrence by strata of estimated glomerular filtration rate (eGFR), whereby PMI was present in only 20.6% of individuals with eGFR ≥ 90 ml/min/1.73 m(2), but was found in 50.0% of individuals with eGFR <30 ml/min/1.73 m(2) (p = 0.004 for trend). Classification of individuals as having either CKD or PMI showed significant differences in adjusted mortality between groups (p < 0.001 for trend), with individuals having both CKD and PMI demonstrating the highest 10-year mortality. Compared to individuals with neither CKD nor PMI, individuals with CKD and no PMI had a hazard ratio (HR) for mortality of 1.64 (95% CI: 1.03-2.63, p = 0.038), while individuals with both PMI and CKD had an HR of 2.08 (1.30-3.33, p = 0.002). CONCLUSION: PMI is common in the CKD population, is inversely related to the level of eGFR, and confers a substantially increased risk in CKD. These findings may partially explain the high mortality traditionally attributed to cardiovascular disease in CKD patients.

The correlation between spontaneous and balloon induced angina: clinical implications.

The clinical implications of variable patterns of spontaneous and balloon induced angina in patients with coronary artery disease (CAD) are not known. We investigated whether the angina pattern a) is reproducible in the catheterization laboratory b) is related to the patient demographics or major risk factors c) predicts the clinical outcomes.

Nanobacteria-associated calcific aortic valve stenosis.

Calcific aortic valve stenosis is the most common valvular disease in developed countries, and the major reason for operative valve replacement. In the US, the current annual cost of this surgery is approximately 1 billion dollars. Despite increasing morbidity and mortality, little is known of the cellular basis of the calcifications, which occur in high-perfusion zones of the heart. The case is presented of a patient with calcific aortic valve stenosis and colonies of progressively mineralized nanobacteria in the fibrocalcific nodules of the aortic cusps, as revealed by transmission electron microscopy. Consistent with their outstanding bioadhesivity, nanobacteria might serve as causative agents in the development of calcific aortic valve stenosis.

Laser extraction of infected pacemaker and ICD leads: early experience at Charleston Area Medical Center.

Infection of pacing and cardioverter defibrillator (ICD) implants is associated with high morbidity and mortality. To report a single center experience of extracted leads, we analyzed 42 (11 ICDs and 31 pacemakers) that had been extracted using laser sheath technology at Charleston Area Medical Center between November 2000 and September 2003. The indications for extractions were infection in 48% of the patients (n = 13) and lead malfunction in 52% (n = 14). In the infection group, 6 patients presented with endocarditis and 7 with pocket erosion and/or infection. Mean patient age was 69.5 years (range 46-96) and mean duration of lead implantation was 68.3 months (range 4-149). Complications with lead extraction occurred in 15% (n = 4); 1 patient had bleeding from right subclavian vein (RSCV); 1 patient had right ventricle perforation; and 2 patients developed cardiac tamponade. One patient with tamponade died despite emergency surgery. During a follow up of at least 8 months (range 8-42), 19% (n = 5) and 7% (n = 2) deaths occurred in the lead malfunction and infection groups respectively. This study shows that extraction is effective in treating pacemaker or ICD infections, but with a significant complication rate.

Persistent left superior vena cava: case reports and clinical implications.

We report four cases of persistent left superior vena cava (LSVC) incidentally recognized during device implantation. Persistent LSVC is the commonest venous anomaly of the thorax and drains into the right atrium via the coronary sinus. Persistent LSVC demonstrates several congenital variations including variable communication with right-sided superior vena cava (SVC), absence of right-sided SVC, drainage into the left atrium creating a right to left shunt, and association with other congenital anomalies of the heart and great vessels. Abnormal persistent fetal dispersion of specialized pacemaker and conduction tissue, which occurs in some individuals with persistent LSVC, may provide an arrhythmogenic substrate. In this article we discuss embryology, diagnostic approaches, clinical features, technical difficulties in accessing the right ventricle, and a review of literature related to persistent LSVC.

Methadone-induced torsade de pointes in a patient with normal baseline QT interval.

Torsade de pointes (TdP) is a life threatening cardiac arrhythmia that is typically associated with prolongation of the QT interval. A wide variety of nonantiarrthymic medications may trigger TdP in patients with prolonged QT interval, only a few reports have described an association between TdP and methadone. We report a case of TdP caused by a large dose of methadone in a patient with presumably normal QT interval at baseline prior to his presentation at the hospital.

Thrombotic thrombocytopenic purpura following cardiovascular surgery: a case report.

Thrombotic thrombocytopenic purpura, a rare clinical syndrome characterized by thrombocytopenia and microangiopathic hemolytic anemia, was almost uniformly fatal until the introduction of plasma exchange in 1970. The thrombotic thrombocytopenic purpura following cardiovascular surgeries is relatively a new entity with high mortality if untreated. Plasma exchange is the most important therapy in this disease with good clinical outcomes. With the addition of this report, there are now 13 cases of thrombotic thrombocytopenic purpura in association with coronary artery bypass graft reported in the literature.

Nanobacteria-caused mitral valve calciphylaxis in a man with diabetic renal failure.

We have found that nanobacteria, recently discovered Gram-negative atypical bacteria, can cause local calciphylaxis on the mitral valve in a setting of high-calcium X phosphorous product in the blood. We present the case of a 33-year-old man with diabetic renal failure on continuous ambulatory peritoneal dialysis who died as a result of multiple brain infarcts due to embolizations from mitral valve vegetations. Systemic calciphylaxis was not present. Spectrometric analysis of the mitral valve vegetations showed that they were composed of calcium phosphate, carbonate apatite form, and fibrin. The electron microscopy of the thrombotic vegetation demonstrated nanobacterium as a nidus for carbonate apatite formation. Investigation for the presence of nanobacteria in the multiple organs involved in systemic calciphylaxis may be of help in elucidating the pathogenesis of this frequently fatal disorder.

Persistent candiduria complicating intraureteral stenting: a case report and review of literature.

Over the past 20 years, there has been a significant increase in the number of nosocomial infections. Nosocomial infections by fungal organisms, in particular Candida species, have shown the highest increase in incidence, currently being the leading pathogen in urinary tract infections and the fourth most common blood-born pathogen within hospitalized patients. This case report describes a patient with acute pancreatitis, complicated by acute renal failure, who developed nosocomial fungiuria and fungemia following bilateral ureteral stenting, and whose fungiuria persisted despite adequate antifungal treatment. Conditions resolved with removal of the intraureteral stents, which we believe, served as the nidus for her persistent fungiuria.